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A school nurse is caring for a child who appears to be having an allergic response. What should be the initial action of the school nurse?
- A. Assess for signs and symptoms of anaphylaxis.
- B. Assess for erythema and urticaria.
- C. Administer an OTC antihistamine.
- D. Administer epinephrine.
Correct Answer: A
Rationale: The correct initial action for the school nurse is to assess for signs and symptoms of anaphylaxis (Choice A). This is crucial as anaphylaxis is a severe allergic reaction that can be life-threatening and requires immediate intervention. Assessing for anaphylaxis symptoms such as difficulty breathing, swelling of the face or throat, and a rapid pulse helps the nurse quickly identify the severity of the situation. Administering OTC antihistamines (Choice C) or epinephrine (Choice D) should only be done after confirming the presence of anaphylaxis. Assessing for erythema and urticaria (Choice B) is important but not as immediate as assessing for signs of anaphylaxis in this scenario.
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Before giving the patient an intermittent gastric tube feeding, what should the nurse do?
- A. Make sure that the tube is secured to the gown with a safety pin.
- B. Inject air into the stomach via the tube and auscultate.
- C. Have the tube feeding at room temperature.
- D. Check to make sure pH is at least 5
Correct Answer: B
Rationale: The correct answer is B because injecting air into the stomach via the tube and auscultating helps confirm the tube placement in the stomach before administering the feeding. This step ensures the safety of the patient by preventing accidental lung feeding.
Choice A is incorrect because securing the tube with a safety pin to the gown is not a standard practice and can lead to complications.
Choice C is incorrect because the temperature of the feeding does not affect the tube placement or safety.
Choice D is incorrect because checking the pH level is not a reliable method for verifying tube placement.
A nurse has provided care to a patient. Whichentry should the nurse document in the patient’s record?
- A. Status unchanged, doing well
- B. Patient seems to be in pain and states, “I feel uncomfortable.”
- C. Left knee incision 1 inch in length without redness, drainage, or edema
- D. Patient is hard to care for and refuses all treatments and medications. Family is present.
Correct Answer: C
Rationale: The correct answer is C because it provides specific, objective information about the patient's left knee incision, including its size and absence of concerning signs. This entry is relevant, concise, and focuses on a specific aspect of the patient's condition, aiding in continuity of care and treatment planning.
Choice A is vague and lacks detail, making it insufficient for accurate patient care documentation. Choice B focuses on the patient's subjective feelings and does not provide objective assessment data. Choice D is judgmental and includes unnecessary information about the patient's behavior and family presence, which is not directly related to the patient's condition.
The nurse is reviewing the health history of a newly admitted patient and reads that the patient has been previously diagnosed with exostoses. How should the nurse accommodate this fact into the patients plan of care?
- A. The nurse should perform the Rinne and Weber tests.
- B. The nurse should arrange for audiometry testing as soon as possible.
- C. The nurse should collaborate with the pharmacist to assess for potential ototoxic medications.
- D. No specific assessments or interventions are necessary to addressing exostoses.
Correct Answer: C
Rationale: Correct Answer: C
Rationale:
1. Exostoses are bony growths in the external auditory canal.
2. These growths can cause narrowing and obstruction of the canal, affecting hearing.
3. Collaborating with the pharmacist to assess for ototoxic medications is crucial to prevent further hearing impairment.
4. Performing Rinne and Weber tests (choice A) and arranging audiometry testing (choice B) are not directly related to exostoses.
5. Ignoring exostoses (choice D) can lead to worsening hearing loss and potential complications.
Following a recent history of dyspareunia and lower abdominal pain, a patient has received a diagnosis of pelvic inflammatory disease (PID). When providing health education related to self-care, the nurse should address which of the following topics? Select all that apply.
- A. Use of condoms to prevent infecting others
- B. Appropriate use of antibiotics
- C. Taking measures to prevent pregnancy
- D. The need for a Pap smear every 3 months E) The importance of weight loss in preventing symptoms
Correct Answer: A
Rationale: The correct answer is A: Use of condoms to prevent infecting others. This is important because PID is a sexually transmitted infection and using condoms can help prevent transmission to sexual partners. It is crucial to address this topic to ensure the patient understands the importance of safe sex practices.
The other choices are incorrect:
B: Appropriate use of antibiotics - While antibiotics are used to treat PID, this choice does not address self-care education for prevention.
C: Taking measures to prevent pregnancy - While important for overall health, preventing pregnancy is not directly related to self-care for PID.
D: The need for a Pap smear every 3 months - Pap smears are not directly related to PID management or prevention.
E: The importance of weight loss in preventing symptoms - Weight loss is not a direct self-care measure for managing or preventing PID.
A patient is being discharged home from the ambulatory surgery center after an incisional biopsy of a mass in her left breast. What are the criteria for discharging this patient home? Select all that apply.
- A. Patient must understand when she can begin ambulating
- B. Patient must have someone to accompany her home
- C. Patient must understand activity restrictions
- D. Patient must understand care of the biopsy site E) Patient must understand when she can safely remove her urinary catheter
Correct Answer: A
Rationale: Step-by-step rationale for why answer A is correct:
1. Ambulating is a crucial postoperative activity to prevent complications like blood clots.
2. Understanding when to ambulate ensures the patient follows proper recovery guidelines.
3. Proper ambulation aids in preventing postoperative complications and promotes healing.
Summary of why other choices are incorrect:
B. Having someone accompany the patient is important for support but not a strict criteria for discharge.
C. While understanding activity restrictions is important, it is not a specific criteria for immediate discharge.
D. Understanding care for the biopsy site is essential but not a strict criteria for immediate discharge.
E. Removal of a urinary catheter is not typically related to discharge criteria for a breast biopsy.